Design Thinking for Health Disparities and Interdisciplinary Knowledge Translation: An LGBTQ+ Youth Health Literacy Project

Abstract

This article discusses the use of codesign, design thinking (DT), and design jams in collaboration with interdisciplinary scholars, service providers, and community-based stakeholders as an approach to social work intervention development—specifically, to tackle health inequities and timely knowledge translation (KT). An application of these methods to the problem of sexual health disparities and lack of access to inclusive sexual health education in school-based settings for LGBTQ+ youth is discussed. LGBTQ+ Youth HeLP (Health Literacy Project) is a holistic online sexual health resource providing evidence-based information to LGBTQ+ youth in an accessible and age-appropriate format. This article considers potential opportunities and obstacles for utilizing DT to develop responsive solutions to health inequities and health-related KT learned from the project. Codesign offers effective options for generating collaborations that may increase cross-stakeholder perspective taking in group settings and produce high-quality outputs with increased likelihood of uptake.

Knowledge translation (KT) is the process of communicating emerging research evidence to key stakeholder groups. While it includes conveying results to scholarly audiences, KT emphasizes distribution of research evidence to nonacademic audiences—such as interdisciplinary service providers, policymakers, and the communities being researched (Graham et al., 2007). KT seeks to bridge the knowledge-to-action gap, an often cited 17-year interval between the generation of research evidence and its widespread adoption in healthcare contexts and by service providers (Morris et al., 2011). KT seeks to reduce (or even eliminate) delays between research and practice, fostering up-to-date best practices in healthcare and providing timely information to stakeholders of a particular health concern (Canadian Institutes of Health Research [CIHR], 2016; Mackay et al., 2015).

One concern that may benefit from expedited KT is sexual health disparities among LGBTQ+ youth—adolescents and emerging adults who identify as lesbian, gay, bisexual, transgender, queer, and other sexual and/or gender minorities. LGBTQ+ youth experience elevated health risks and negative outcomes related to multiple dimensions of sexual health, including consent, physical well-being, and family planning (Everett et al., 2014; Saewyc, 2011). Simultaneously, youths’ access to LGBTQ+ specific sexual health knowledge is deficient (Kosciw et al., 2020). Evidence-based educational resources specific to this population are necessary to reduce disparities and would be most effective if framed and delivered in ways relevant to the target audience.

Active participation of individual stakeholders and stakeholder groups in the creation of a responsive solution to a specific problem has been conceptualized as codesign (Sanders & Stappers, 2008). A methodology for facilitating codesign is design thinking (DT). Employed for building up authentic, innovative solutions in a judgment-free environment (Simon, 1969), DT is a valuable practice when a specific problem is poorly understood or current solutions are noticeably inadequate (Roberts et al., 2016). Consistent with social work values and ethics, DT is human-centered and empathetic (Kouprie & Visser, 2009; Liedtka, 2015), encouraging multidisciplinary, community-engaged collaborations with a range of perspectives and expertise (Van Mechelen et al., 2019). While social workers should be wary of adopting practices or procedures out of novelty (McMillin, 2014), DT methods have potential to accelerate the mobilization of research evidence into real-world practice.

This article discusses application of DT with interdisciplinary stakeholders to the problem of sexual health disparities and lack of inclusive sexual health education in school-based settings for LGBTQ+ youth (Everett et al., 2014; Hafeez, 2017; Kosciw et al., 2020; Saewyc, 2011). Through a design jam—a specific DT method that mandates rapid brainstorming and evidence-based prototype development—an educational resource was created to address these gaps. The developed solution, LGBTQ+ Youth HeLP (Health Literacy Project), is a holistic online resource providing reliable, evidence-based sexual health information to LGBTQ+ youth in an accessible and age-appropriate format. Following discussion of the DT process for LGBTQ+ Youth HeLP, this article discusses potential opportunities and obstacles encountered during project development for utilizing this approach in interdisciplinary collaborations to create responsive solutions to health inequities and health-related KT.

Knowledge Translation

KT incorporates a range of terminologies that are often used interchangeably, and which may (or may not) entirely align (Graham et al., 2006). For example, it has alternative names in particular disciplines or geographic regions (e.g., knowledge mobilization; Social Sciences and Humanities Research Council of Canada [SSHRC], 2019). Terms like “research dissemination” and “knowledge diffusion” also evoke similar concepts. However, dissemination tends to describe conventional systems of sharing research evidence, while diffusion designates the spread and adoption of an idea over time (Graham et al., 2006). KT emphasizes purposefulness, nonscholarly audiences, and timeliness of research uptake (Graham et al., 2007; Mackay et al., 2015). Depending on the discipline—as well as the type of research being conducted and its objectives—KT may have an array of intended outcomes and applications. Consequently, it encompasses a variety of efforts and activities, all of which require (and benefit from) participation of multiple stakeholder groups (CIHR, 2016).

As illustrated in Figure 1, stakeholders may be involved in the synthesis, dissemination, exchange, and/or application of research knowledge (Graham & Tetroe, 2009). Synthesis refers to combining and arranging a body of related research evidence into more manageable and understandable formats, ranging from researcher-oriented meta-analyses or systematic reviews to policy briefs or plain-language summaries (Wyborn et al., 2018). Dissemination is the process and activities associated with communicating specific research evidence adequately and in a way that is understandable to the intended audiences, such as community members or service providers (Graham & Tetroe, 2009). Dissemination may include traditional information provision, supporting decision-making ability, and engaging individuals in their own knowledge journey (Chapman et al., 2020). Exchange refers to the reciprocal and mutually beneficial process of sharing information between stakeholder groups, including among researchers, service providers, participants, and/or funders (e.g., café scientifiques; Graham & Tetroe, 2009). This omnidirectional communication process can (and should) cross tiers of hierarchy (e.g., between groups, from individuals to organizations), and reflects the mutual nature of collaboration (Goering et al., 2003). Finally, application refers to ethically sound processes and evaluation necessary for integrating emerging evidence-based knowledge into the common practices of a field, systematically building on currently understood best practices (Graham & Tetroe, 2009). Application has been noted as a nonlinear process, can be evaluated using implementation science approaches, and may face skepticism from practitioners and/or consumers who have yet to “buy in” to the emerging processes (Orem et al., 2014).

Figure 1:

Knowledge Translation Process

Integrated KT (IKT) involves key stakeholder input across all phases of research and dissemination (Graham & Tetroe, 2009), sharing similarities with community-based participatory research (CBPR). Both incorporate members of stakeholder groups throughout the knowledge generation cycle, which may lead to more rapid KT and adoption of research evidence (Jull et al., 2017). However, CBPR is a distinct research methodology rooted in elevating the perspectives of activists and marginalized groups otherwise shut out of the research process (Jull et al., 2017). In contrast, IKT is more recently developed—instigated primarily by research funders—to encourage scholars using various methodological approaches to engage on an ongoing basis with stakeholder groups impacted by their research efforts (Denis & Lomas 2003). IKT practices are still becoming formalized (Jenkins et al., 2016), and research is ongoing into the sustainability and economic viability of various KT and IKT approaches (Tricco et al., 2015). IKT frameworks ensure that collaborative principles are upheld and that emerging researchers, regardless of epistemological or methodological approach, have opportunities to engage in this meaningful work (Gainforth et al., 2021). IKT involvement has been found to have positive effects in social work, including increasing participating social workers’ self-efficacy, collaboration, and use of research in their professional practice (Wilkinson et al., 2012).

Community Codesign and Design Thinking

Evolved in the 1970s (Sanders & Stappers, 2008, 2012), codesign is difficult to concisely define due to a range of overlapping and interchangeable terminology (Van Mechelen et al., 2019). Fundamentally, it is an established approach to equitable engagement of relevant parties during problem resolution (Sanders & Stappers, 2012). It is marked by the active involvement of members from multiple areas of expertise, professional contexts, and social locations codesigning a responsive solution to a specific problem, and can occur within a variety of settings. Like CBPR, codesign may be understood as collaborative, as well as democratizing or even empowering to those involved (Sanders & Stappers, 2012). However, in reality the process may vary in the level of influence offered to various stakeholders (Steen et al., 2011). Broadly speaking across allied health disciplines, involving stakeholder groups in the iterative process of designing a program, intervention, or other solution to address a defined problem is considered a form of codesign.

DT has similarly varied definitions and approaches (MacFadyen, 2014). As a particular codesign methodology, the specific activities of DT are generally understood to follow three main steps: need finding, brainstorming, and prototyping (Brown, 2009). While DT has identified potential across a range of fields—including health technology (Leorin et al., 2019) and coordinated medical and behavioral care (Ankeny & Barrie, 2019; Steen et al. 2011)—it has remained underutilized in developing solutions for service gaps and sociobehavioral healthcare problems commonly tackled by social workers and the interdisciplinary teams on which they serve. In need finding, both experts and nonexperts (a) collaborate to explore existing solutions (e.g., technologies, interventions, programs) that may address a defined problem of importance to them and (b) identify gaps in existing solutions that necessitate new designs. During brainstorming the collaborators propose multiple ideas to address the identified gaps. This step is characterized by participants actively adding to or modifying others’ ideas, emphasizing the cooperative nature of DT. Oftentimes ideas emerge that would not have been generated in noncollaborative settings. Finally, prototyping involves further development of one (or more) of the ideas into a tangible solution, which can be observed or tested on the problem. Elements of these processes can be found in formalized DT models, including the model used in developing LGBTQ+ Youth HeLP—a design jam.

A design jam is an event in which one or more teams of collaborators work through the steps and activities of DT in a condensed time period (from several hours to several days) to develop a solution for a particular type of problem (Kuzmina et al., 2016). That is, a problem where robust evidence exists, research suggesting or supporting possible solutions may exist, but no tangible solutions have yet been developed. As with other forms of DT, design jam teams are typically multidisciplinary and collaborative, incorporating both professionals and nonprofessionals (e.g., end users, community members), with all individuals assumed to have skills and expertise to contribute to the project (Kagan et al., 2020). However, in contrast to traditional DT—which may require more time, have a linear structure, or have a distinct team hierarchy—design jams are typically structured to permit a functional prototype to emerge by the end of the relatively short-term event (Kuzmina et al., 2016) and have demonstrated utility for rapid technological development (Overkamp & Holmlid, 2015).

In general, the structure and team composition of design jams meet the following conditions: (a) the pressing topic or problem is preselected, (b) team members each have applicable skills or knowledge related to the problem, (c) rules and procedures are agreed upon beforehand, (d) the setting is mutually unfamiliar or dissimilar to participants’ typical work settings, and (e) all participants have equal opportunity to contribute (Carlsson et al., 2014). As illustrated in Figure 2, during the design jam process the team identifies gaps in extant solutions they intend to address, enters the brainstorming phase in which all ideas are considered, and prototype assembly begins. Once an initial prototype is developed, it is reviewed, and brainstorming recommences in an iterative loop. This process repeats several times until a mutually agreed-upon tangible prototype is created to be presented to the sponsors (i.e., pitched).

Figure 2:

Design Jam Process

Once prototypes are pitched, sponsors often engage in a judging or evaluation process (Vezzani & Tang, 2014). Pitches must include actionable plans for resource allocation or project implementation (Kuzmina et al., 2016; Overkamp & Holmlid, 2015). Depending on the sponsors and the goal of the design jam, prizes and/or funding may be awarded at the end of the event (Vezzani & Tang, 2014). Prizes may be related to prototype implementation, such as meeting with developers or coaches who will guide the team in future development (Kuzmina et al., 2016). However, research literature is scant on the outcomes and future developments of highly rated design jam prototypes. This article illustrates strategies used in the implementation phase of a design jam prototype in the mental and behavioral health space as a resource for future research.

The LGBTQ+ Youth HeLP Design Process

The design jam was organized and funded by CIHR (2019) “to foster creative problem-solving” for health-related knowledge translation challenges experienced by individuals who identify as LGBTQ+. The funders established the pressing problem area and brought together interdisciplinary teams to identify health knowledge gaps within their areas of expertise and experience. The team for LGBTQ+ Youth HeLP were scholars and service providers specializing in LGBTQ+ mental, behavioral, and sexual health—with a particular emphasis on adolescent and emerging adult populations. One of the project coleads (first author) was a social work scholar. The team undertook the methodical, multiphased process of DT during a two-day design jam, while accompanied by a team facilitator, a graphic designer, and an LGBTQ+ young person representing the target community.

Design Jam: Need Finding

Due to the limitations of the two-day design jam format, need finding for LGBTQ+ Youth HeLP was based predominantly on the defined scope of the funders and scholarship regarding LGBTQ+ youth health disparities. Sexual health is an integral component of young people’s physical and mental health (World Health Organization, 2006), including sexually transmitted infections (STIs) and reproductive health, as well as healthy relationships, sexual self-expression, body image, and self-esteem. Sexual orientation and gender identity are also deeply connected to young people’s sexual health, affecting both their overall sexual health and their access to healthcare services and education (Maticka-Tyndale, 2008). Research has established significant sexual health disparities between LGBTQ+ youth and their non-LGBTQ+ (i.e., cisgender, heterosexual) peers. These manifest as higher rates of negative sexual health outcomes, and greater likelihood to engage in higher-risk sexual behaviors (Coker et al., 2010; Hafeez et al., 2017). Specific disparities for LGBTQ+ youth include higher rates of pregnancy (Saewyc, 2011; Stoffel et al., 2017), STI transmission (Coker et al., 2010; Everett et al., 2014; Saewyc, 2011), and experiences of sexual coercion (Everett et al., 2014). However, it is important to contextualize these disparities within the reality of the hostile climates of discrimination and victimization LGBTQ+ youth experience in their homes, schools, and communities—which contribute to an assortment of health-related vulnerabilities (Saewyc, 2011).

Sexual health education is meant to teach young people how to avoid negative health outcomes, as well as foster healthy relationships through communication and understanding (Bridges & Hauser, 2014). However, the access of LGBTQ+ youth to education that addresses their specific sexual health needs is severely restricted. One recent study across the United States found less than 20 percent of LGBTQ+ youth who received sex education in school reported the curriculum was LGBTQ+ inclusive. However, due to the lack of any sex education in many school settings, less than 10 percent of all LGBTQ+ students surveyed actually received inclusive sex education (Kosciw et al., 2020). In many sexual health education curricula, heterosexual relationships are prioritized and LGBTQ+ identities are minimized, excluded, or erased (Gowen & Winges-Yanez, 2014; Martinez & Phillips, 2008). Access to accurate and relevant information—particularly before adolescents become, or are just becoming, sexually active—is paramount to addressing the sexual health needs of LGBTQ+ youth, fostering healthy behaviors, and mitigating potential risks (Everett et al., 2014).

Given that access to sexual health education is often unavailable in school and community-based settings, many youths (regardless of sexuality or gender identity) turn to online resources to find information that is stigma-free, up-to date, accessible, anonymous, and convenient (Chang et al., 2017; Fergie et al., 2013). Research indicates that 84 percent of youth in the United States have relied on online resources for health information, with approximately one-fifth accessing sexual health information (Wartella et al., 2015). However, despite advancements in online resources, internet-based sexual health websites are not always accessible or beneficial for youth. Many have educational deficiencies in the content, usability, authority, and interactivity. Additionally, the information can be insufficient or unreliable; the websites are hard to navigate, or text-dense, or they do not allow users to actively engage with the information provided (Whiteley et al., 2012); and there is a lack of accountability regarding accurateness and reliability (Hawkins & Watson, 2017; Kosciw et al., 2020).

With the dearth of LGBTQ+ information in school-based curricula, it is unsurprising that LGBTQ+ youth were found in one study to be over five times more likely than their non-LGBTQ+ peers to research sexuality and sexual attraction online (GLSEN et al., 2013). Substantial numbers of LGBTQ+ youth in the same study also searched for information on STIs and general health (GLSEN et al., 2013). Research indicates that LGBTQ+ youth are relying heavily on the internet for necessary information and support, using online resources to acquire a variety of information related to sexuality, gender identity, and sexual health. As a result, internet-based, evidence-informed interventions have the potential to be effective in facilitating the sexual health needs of LGBTQ+ youth (DeHaan et al., 2013; GLSEN et al., 2013; Mustanski et al., 2015).

Design Jam: Brainstorming and Prototyping

Effective sexual health information has been shown to reduce risk behaviors and facilitate positive sexual health outcomes (Lindberg & Maddow-Zimet, 2012). However, given the aforementioned deficiencies, current online resources are insufficient. Once this problem was specified as the focal gap to address for the team, the next step in the design jam began—brainstorming. Numerous potential solutions were proposed and built on before being adapted or discarded. Ideas included published lists of where to access information online, as well as creating a video-based webseries. Consideration was given to feasibility (e.g., team capacity, resource constraints), likelihood of effectiveness, sustainability (e.g., platform maintenance), expertise, and interest. The team sought to create a solution that would have the greatest impact in the shortest amount of development time, reduce geographic barriers for youth outside urban areas, and mitigate other common impediments LGBTQ+ youth encounter when attempting to obtain health information.

Following the iterative brainstorming process, a reliable online sexual health knowledge hub for LGBTQ+ adolescents and young adults (ages 12+) was proposed and prototyped (see Figure 3). The knowledge hub would seek to translate extant reliable and accurate research evidence on LGBTQ+ sexual health in a way that was accessible, engaging, and targeted to the needs of youth while simultaneously leveraging existing good-quality online resources.

Figure 3:

The Prototype

During the iterative process of prototyping during the design jam, the hub was progressively conceptualized to effectively communicate sexual health information to younger (i.e., early adolescent) LGBTQ+ youth, for whom good-quality resources may be least accessible or comprehensible. Emphasis was also increased on holistic sexual health (i.e., physical, mental, emotional), stressing overall well-being through highlighting elements such as self-image and sexual self-expression (Maticka-Tyndale, 2008). These changes were due to (a) the lack of LGBTQ+ sexual education in secondary-school curricula (Martinez & Phillips, 2008; Gowen & Winges-Yanez, 2014); (b) the limited youth-friendliness of existing online resources for LGBTQ+ sexual health that are traditionally targeted to adults; and (c) the evidence that accurate and relevant sexual health information before or during the onset of sexual activity supports healthy sexual behaviors (Everett et al., 2014). The central purpose was focused on synthesis and dissemination of extant research largely inaccessible to young people, providing reliable, evidence-based sexual health information in a centrally located, accessible, and age-appropriate format.

The prototype featured easily sharable and interactive content that was relevant and inclusive, as well as trustworthy and safe. The team determined that working from scratch and duplicating already existing content that met the site criteria was inefficient. Instead, a hub-type model was proposed, with the planned platform acting as a centralizing source of good-quality, evidence-based knowledge from reputable sources (e.g., Planned Parenthood) already online. Recommendations for unique, site-specific content included topic summaries; short, animated videos; and guides to help youth navigate potential barriers to accessing healthcare (e.g., finding a competent healthcare provider) and support them in having challenging conversations around sexual health (e.g., with romantic and sexual partners). The prototype ultimately incorporated components of several original brainstorming ideas, including centralizing existing content and incorporating video elements. A language decoder was also proposed, recognizing that the language of both the LGBTQ+ community and healthcare settings could potentially be intimidating or inaccessible to younger LGBTQ+ site users.

At the end of the process, the prototype was pitched to the funders. It received the highest overall score for the design jam as well as a prize. As is typical in a pitch, the presentation was brief, consisting of eight slides, with the team having three to five minutes to identify the specific problem and describe their proposed solution.

Postdesign Jam: Implementation

Following the design jam, funding was provided for implementation of the prototype. Over approximately six months, a final framework for LGBTQ+ Youth HeLP (https://youthhelp.net) was developed that, in addition to emphasizing holistic sexual health, was grounded in bodily integrity and sex positivity, and challenged the gender binary. Bodily integrity is a person’s freedom to dictate how their own body is used, particularly with regard to their own sexual and reproductive health (Nussbaum, 1999). Definitions of sex positivity are more broadly concerned with the attitude that sexuality is an important, pleasurable experience for individuals across the range of human sexual expressions (Williams et al., 2013). Challenging the gender binary refers to research and practice countering or disrupting dominant assumptions that gender is innately tied to sex assignment at birth and can only be divided into categories of male and female (Hyde et al., 2019). Additionally, health concerns (e.g., substance use, self-harm) and sociodemographic factors (e.g., disability, race) tied in the literature to the quality of sexual health for LGBTQ+ individuals were interwoven to facilitate site inclusivity.

The features proposed in the prototype underwent further iterative development and resulted in the features of the final site, which attended to the realities of youths’ engagement with online environments. The features and content of the site were variable and included shareable, “bite-sized” content such as videos and social media posts to draw in youth seeking more information; TL;DRs (“too long; didn’t read”s), which are summaries of important content; and terminology decoders to explain healthcare and community jargon. Trustworthiness and credibility of the content were emphasized through organizational logos and links to credible existing resources. Safety and security were enhanced for youth through a rapid site exit button and safe browsing instructions. To ensure that immediate needs were met, 24/7 crisis resources were also made available. Original content and links to resources were provided in four categories: (1) body and brain (e.g., self-care, gender, harm reduction); (2) relationships (e.g., coming out, relationship types, consent, abuse); (3) sex (e.g., safer sex, STIs and genital infections, pregnancy, parenting choices); and (4) clinics and services (e.g., LGBTQ+ friendly clinics, testing, hormone therapy). Finally, practical guides were offered with accompanying videos on finding an LGBTQ+ competent healthcare provider, preparing for an appointment with a provider, and talking about sex.

There are indications that LGBTQ+ populations—including youth specifically—may be particularly active online (GLSEN et al., 2013; Pew Research Center, 2013). Emphasis was placed on ensuring HeLP was intuitively navigable and mobile friendly, as adolescents and young adults in the United States are extremely active online via mobile devices. Nearly all adolescents (95 percent) have smartphone access, and almost half (45 percent) are online “almost constantly” (Schaeffer, 2019). The development of Youth HeLP focused on visual content and clear linkages to the site’s accompanying social media accounts, as youth internet and social media use heavily incorporates primarily visual and photo-sharing platforms such as Instagram, Snapchat, and TikTok (Lenhart & Page, 2015). Likewise, Youth HeLP sought to make information freely and easily available in a familiar format, as most youth describe using their phones and mobile devices as a way to access and learn new information (Schaeffer, 2019).

Additional members were added to the team throughout implementation, nearly all of whom were young adults who identified diversely as members of the LGBTQ+ community. These members within the age range of the target population were hired to curate existing online content, as well as generate site-specific content. They contributed significantly to the site’s aesthetic and its material. In addition, two public health professionals specializing in the target population were hired to review and revise the drafted site content. One professional held expertise related to the sexual health of LGBTQ+ communities of color, particularly Black LGBTQ+ youth. This individual’s hiring was spurred by ongoing self-reflexivity, and recognition of a gap in representation and expertise on the implementation team.

Compatibility of Design Thinking with Access to Evidence-Based Knowledge

Communicating research evidence to service providers may be hampered by the realities of their lack of time, access, interest, and/or efficacy toward critically consuming, appraising, and applying new information (McNeill, 2006). These same realities also inhibit the access, likely to an even greater degree, of the communities being studied (e.g., LGBTQ+ youth) and other community-based stakeholders (e.g., parents, community leaders). A proposed solution to this problem is user-friendly synthesis of research. However, research synthesis persists too often only in scholarly works (e.g., systematic reviews, meta-analyses), which does not really mitigate its unapproachability. KT is made more effective through purposefully practice-oriented communication (e.g., practice guidelines, narrative descriptions of research, easily consumed visual tables; Kelechi & Naccarato, 2010), as well as development of realistic practitioner education opportunities and greater availability of multiple learning technologies (Wyborn et al., 2018). It is made more effective still through the development of corresponding resources and opportunities for community-based dialogue (e.g., social media campaigns, community meetings) tailored to the comprehension of the target populations (Chapman et al., 2020). It is worth emphasizing, however, that social work and other health and social service professions should be wary of adopting new knowledge or practices based solely on perceptions of gaining large market shares. Instead, these disciplines should be focused on advocating for the access of target populations to the codesign processes and outcomes—making interventions available in equitable, socially just ways (McMillin, 2014).

Codesign and DT projects are effective for incorporating multilayered perspectives and multiple stakeholder groups into the knowledge-to-action pipeline. Such collaborations produce high-quality outputs, with no indications of shortcuts or inaccuracies, and may increase the likelihood that various stakeholders will participate in future collaborations (Ankeny & Barrie, 2019). In addition, several explorations of codesign have uncovered unanticipated benefits, particularly that codesign projects improve creativity and require all members to imagine themselves in the positions of others and design from a multitude of different perspectives (Hodson et al., 2019; Steen et al., 2011). This results in service providers experiencing greater capacity to understand their clients’ needs, and clients often increasing their engagement if they believe their needs are being adequately recognized by providers, administrators, and others (Steen et al., 2011). A similar process may occur between researchers and participants.

Opportunities

Despite efforts to incorporate stakeholders into research and dissemination processes, their integration within healthcare and social services remains deficient. This may be due (at least in part) to inadequate implementation of research-related activities that encourage equitable collaboration amongst numerous stakeholder groups (McMillin, 2014; McNeill, 2006). A hallmark of codesign is incorporation of perspectives and participation from people who lack experience or expertise with elements unique to the particular field for which the intervention is being designed (Sanders & Stappers, 2008). It is also important to incorporate members of the relevant stakeholder groups in the design processes, resulting in multidisciplinary collaborations between diverse team members who may not have interacted otherwise (Steen et al., 2011). Such an array of perspectives allows the brainstorming process to incorporate many different ideas and allows for the groupthink to envision “what could be” (Steen, 2011). The process explicitly encourages creativity with an ethos that no idea can be dismissed as absurd or foolish (Simon, 1969). Oftentimes considering the different ideas or placing oneself in another’s unfamiliar shoes may lead to a “breaking the logjam” moment whereby team members can better develop workable solutions (Roberts et al., 2016).

Projects such as LGBTQ+ Youth HeLP demonstrate the utility of codesign approaches. As discussed, LGBTQ+ youth experience greater barriers to adequate sexual health education, and disparate sexual health outcomes (Coker et al., 2010; Everett et al., 2014; Hafeez et al., 2017; Kosciw et al., 2020); other minority populations experience similar difficulties accessing health information and evidence-based care (Duran & Pérez-Stable, 2019). DT offers the potential to address health problems by creating innovative, evidence-based solutions in collaboration with communities that may be experiencing knowledge gaps, health disparities, or other health-related obstacles. Codesigned solutions allow intervention and implementation strategies to be tailored specifically to communities with the highest levels of need.

Another opportunity of DT is the rapid progress of KT implementation. Instead of the years typically required to move research knowledge to practical application, approaches like design jams are guaranteed to produce workable prototypes within the space of several hours to a few days (Vezzani & Tang, 2014). After the prototyping phase, potential solutions can be further developed or adapted on reasonable timelines, offering community members, service providers, and other stakeholders a range of options for ongoing participation during implementation (Kuzmina et al., 2016; Overkamp & Holmlid, 2015). Since the codesign process occurs with end users as both foci and participants, DT quickly progresses to tangible tools for use rather than distant concepts that are withheld for long periods of time (Sanders & Stappers, 2008).

Obstacles

Although codesign has a variety of strengths that can lead to rapid innovation in healthcare settings, there are difficulties which must be considered. Most notably, DT requires a strong, cohesive team effort among participants (Carlsson et al., 2014). As team members may be from disparate disciplines and potentially have not engaged in prior work together, it may take time for the team to build trust and working relationships (Sanders & Stappers, 2008). In settings such as a design jam, this can be particularly challenging. Time constraints do not offer the luxury of devoting hours or days to exercises that adapt team members to their counterparts’ respective working styles (Kuzmina et al., 2016; Vezzani & Tang, 2014). This was a challenge for the LGBTQ+ Youth HeLP team, who were assembled by the funder explicitly for the design jam event. It took well into the implementation phase for the team to develop a stable working relationship that suited all parties involved.

Likewise, bringing a team together from different disciplines and stakeholder groups can inevitably result in a power imbalance among team members. The purpose of DT is to treat everyone as an expert in their own professional domain or experience of the problem (Sleeswijk Visser et al., 2005). However, a significant challenge in participatory research designs is ensuring that all stakeholders maintain adequate input (Gagliardi et al., 2015). This issue may manifest between stakeholder groups (e.g., between professionals and community members), but also within stakeholder groups based on within-group power disparities (e.g., the hierarchy of healthcare professionals, demographic differences between community members; Oliver et al., 2019). When coupled with the aforementioned team-building challenges, especially in the truncated time frame of a design jam, various team members may find themselves vying for some amount of power or for their perspectives to be prioritized.

To prevent power differentials and support collaborations, strong team facilitation is necessary (Sanders & Stappers, 2008). However, this itself can present as a challenge. Having someone act as facilitator—whether as a contributing member of the team or as a third party whose sole responsibility is facilitation—may reinforce power differentials (Oliver et al., 2019). Group facilitation must be responsible, fair, and just. The time constraints of DT and design jams also require teams to move quickly through phases of development (Vezzani & Tang, 2014). Strong facilitation requires a group to stay on task, but also may lead group members from communities lacking structural power to feel as if their own work was not fully or properly considered (Turnhout et al., 2020). Research has supported the notion that facilitators are particularly effective if they are able to communicate with participants in a common language (Wardale, 2013), yet finding facilitators capable of engaging in such a way with all relevant stakeholders simultaneously is itself a daunting task.

In addition to team-related difficulties, other types of obstacles may also create difficulties for DT. For design jams specifically, examples include immediate and long-term feasibility issues due to the reliance on external funding sources or in-kind contributions from organizers to support prototype refinement and implementation (Kuzmina et al., 2016). In the case of LGBTQ+ Youth HeLP, both these issues were present during the implementation process due to funder restrictions and lack of follow-through on the team’s pitch prize, which included in-kind support from a supporting organization. Gaps in necessary technical or team expertise without time to recruit additional individuals due to the protracted timeline is another common challenge.

Conclusion

To address the problem of sexual health disparities and lack inclusive sexual health education for LGBTQ+ youth in school-based settings (Everett et al., 2014; Hafeez et al., 2017; Kosciw et al., 2020), a potential solution was developed through the application of DT in a design jam format with interdisciplinary stakeholders. The result was a holistic online sexual health knowledge hub providing reliable, evidence-based sexual health information in an accessible and age-appropriate format. Codesign, DT, and design jams offer potential challenges for developing responsive solutions to problems within interdisciplinary healthcare settings. However, such projects simultaneously offer opportunities for closing the knowledge-to-action gap by fostering collaborations that produce cross-stakeholder perspective taking within groups (Hodson et al., 2019; Steen et al., 2011) and high-quality KT outputs with increased likelihood of uptake (Ankeny & Barrie, 2019).

 

This research was supported by funding from the Canadian Institutes of Health Research [#ICSI55522 and #ICS-201703].